Here we look at how A&E waiting times have changed over the past few years and explore the complex causes of the problems in A&E, which reflect wider pressures on the NHS and social care.
- What is the A&E standard and how is the NHS performing?
- Has the number of people going to A&E increased?
- Is the pressure on A&E a result of people going to A&E when they should go somewhere else?
- How is A&E performance affected by pressures within hospitals?
What is the A&E standard and how is the NHS performing?
The NHS Constitution sets out that a minimum of 95 per cent of patients attending an A&E department in England must be seen, treated and then admitted or discharged in under four hours. This is one of the ‘core standards’ set out in the NHS Constitution and the NHS Mandate, and is often referred to as the four-hour A&E target.
A letter sent out by NHS Improvement in December 2016 announced a review of how hospital performance will be measured. The new ‘oversight framework’ will capture a broader perspective of hospital performance whereby, though the 95 per cent standard will remain the key system indicator, there will also be further metrics on clinical standards and patient and staff experience.
At the time of publishing there have been no further announcements on the content or timing for the introduction of this framework.
Performance against the four-hour standard
So far in 2016/17 the NHS has not met the four-hour standard, failing it every month of the year. The standard has now not been met for the past 17 months.
In quarter 3 2016/17 (October to December 2016), the proportion of patients spending longer than four hours in A&E reached its highest level for this time of year in more than a decade. Only 4 out of 139 hospitals with major type 1 A&E departments (see box, below, for details) met the standard. It is now certain that 2016/17 will be the third year running that the NHS will miss the standard across the year as a whole.
Types of unit
- Type 1 A&E department – major A&E, providing a consultant-led 24 hour service with full resuscitation facilities
- Type 2 A&E department – single specialty A&E service (eg ophthalmology, dentistry)
- Type 3 A&E department – other A&E/ minor injury unit/ walk-in centre, treating minor injuries and illnesses
Figure 1 shows A&E waiting time performance since 2003/4. From 2005 to 2010 the proportion of patients spending more than four hours in A&E hovered around 2 per cent – in line with the 98 per cent target introduced in 2000 and first met for a full year in 2005.
However, since April 2011, when the coalition government relaxed the target to 95 per cent, the proportion of patients waiting longer than four hours has increased.
Figure 1 also shows how performance against the four-hour standard tends to improve in the summer months.
However, while performance recovered in the summer of 2016/17, it still breached the standard.
Has the number of people going to A&E increased?
For many years, the number of people attending A&E remained unchanged at around 14 million a year.
In 2003/4, the number of attendances jumped – by nearly 18 per cent – to 16.5 million. This reflects the decision around this time to incorporate data from walk-in centres and minor injuries units (type 3 units) in the figures. These units aimed to improve patients’ access to primary care, be more responsive to patients’ busy lifestyles, and offer patients more choice (Monitor 2014).
Since 2003/4, the overall number of attendances has increased significantly, rising to 22.9 million in 2015/16, an increase of more than 39 per cent. Until 2012/13, attendances in type 3 units accounted for the vast majority of this increase, with attendances in type 1 units increasing at a much lower rate.
More recently attendances at type 1 and 3 units have increased at a similar rate: between 2013/14 and 2015/16 there were increases of 5 and 6 per cent in attendances at type 1 and 3 units respectively (NHS England 2017).
While attendances have increased and performance has worsened over the past few years, attendances at A&E departments is not the main factor affecting performance. The seasonal trend in attendances supports this: A&E attendances tend to be higher in the summer and lower in the winter when performance tends to be worse. For example, data for 2016/17, show June and July were busier months for attendances with 65,259 and 67,032 per day than November (63,562) and December (62,696). Yet performance against the four-hour standard was worse in the winter.
There are various factors driving this, in particular that during the winter months there is an increase in the proportion of older people attending and in the proportion of people who need to be admitted to a hospital bed as an emergency. This was highlighted in our March 2017 quarterly monitoring report. 80 per cent of NHS trust finance directors responding to our survey identified increasing numbers of patients with severe illnesses and complex health conditions as one the key factors behind the rising pressures on A&E departments (2016/17).
Is the pressure on A&E a result of people going to A&E when they should go somewhere else?
Around 11 per cent of people who attend A&E are discharged without requiring treatment, and a further 38 per cent receive guidance or advice only (NHS Digital 2017). This does not mean that all these people are attending A&E unnecessarily or could be cared for elsewhere. For example, someone who leaves A&E without being admitted to a hospital bed may well have attended appropriately because they required treatment or assessment that only A&E could provide.
Three of the claims put forward for why people go to A&E unnecessarily are examined below.
Lack of access to GP appointments
It has been suggested that more people are attending A&E because they can’t get appointments with their GP. It is difficult to pin down accurately how many people this might apply to.
However, the latest results from the GP Patient Survey (July 2016) show that 85 per cent of people were able to get an appointment to see or speak to someone at their GP practice, down from 88 per cent in 2011. Of those who couldn’t get an appointment or who were offered an inconvenient appointment (11 per cent), around 4 per cent reported going to A&E instead.
We know that being able to obtain timely appointments is a key concern for people accessing GP services. However, the data from the GP Patient Survey suggests that while there has been a slight reduction in people’s ability to access their GP, there has not been a significant deterioration.
Access to out-of-hours care and care out of hours
It has been suggested that removing responsibility for out-of-hours care from GPs (as part of contractual changes in 2004) led to an increase in A&E attendances. However, there is no evidence to support this.
Most people go to A&E on weekdays between 9am and 5pm, when GP surgeries are open. However, people are clearly uncertain about how to access care when their GP surgery is closed (out-of-hours care) – results from the GP Patient Survey in July 2015 found that only 56 per cent of people said they knew who to contact out of hours. While this is higher than 2014, it is lower than in previous years.
Access to other types of care out of hours (for example, district nursing care) is also important in keeping people out of hospital. We know that the number of district nurses employed by the NHS has decreased by about 41 per cent in the past six years and that district nursing services are under increasing pressure.
Confusion among patients about where to go
The Keogh review into the urgent and emergency care system expressed concerns that the fragmented provision of services makes the system confusing for the public. In response to these concerns, the NHS five year forward view committed to doing ‘far better at organising and simplifying the system’, with the aim of helping patients to ‘get the right care, at the right time, in the right place’ by making more appropriate use of primary care, community mental health teams, ambulance services and community pharmacies.
To support this, NHS England has been undertaking a review of urgent and emergency care. Eight of the vanguards set up to explore new models of care have been pioneering new approaches to delivering urgent and emergency care services, and many of the proposals laid out in sustainability and transformation plans aim to provide better support in the community to alleviate pressure on urgent and emergency care.
How is A&E performance affected by pressures within hospitals?
Are more patients being admitted to hospital from A&E?
Evidence suggests that more people are being admitted to hospital from A&E. Compared to 2011/12, in 2015/16 there were an additional 481,295 hospital admissions from A&E departments in England; a growth of 13 per cent over this period.
Admissions from A&E in the first three quarters of 2016/17 are up by more than 3 per cent compared to 2015/16. This is the equivalent of more than 13,160 additional people a month.
As the number of people admitted from A&E into hospital wards has increased, so have waiting times. This is because people waiting for admission to hospital tend to wait longer in A&E than people who can be treated in A&E or who are discharged without treatment (Blunt 2014).
As more people wait in A&E departments for admission to a bed in hospital, there is an increasing risk that A&E staff have to be diverted to looking after them and that the A&E department simply runs out of space. Should this happen then all patients may need to wait including those who do not need a bed. Where this happens A&E performance against the four-hour standard can worsen very sharply.
How is performance affected by bed-occupancy rates?
High bed-occupancy rates are often associated with worsening A&E performance. In 2016/17, most hospitals are operating at bed-occupancy rates above 85 per cent – the level at which the Department of Health suggests hospitals will struggle to deal with increasing demand for emergency admissions.
Weekly data from NHS England covering winter (December 2016 to February 2017) shows that over this period the national bed-occupancy rate has been closer to 95 per cent. The Royal College of Emergency Medicine has commented that this level of bed occupancy is ‘unsafe’.
In the third quarter of 2016/17, the number of people who waited in A&E departments for admission to a hospital bed (often described as ‘trolley waits’) for more than four hours after the decision to admit them was 15 per cent, or more than 164,565 people. Furthermore, the year-to-date figures for 2016/17 show an additional 151,973 people waiting more than four hours compared to 2015/16 (see Figure 4).
There has been a particularly sharp rise in the number of patients waiting more than 12 hours from decision to admit to admission. In the third quarter of 2016/17 there were 1,257 such patients compared to just 116 in the same quarter in 2015/16.
Are delays in discharging patients from hospital having an impact?
Delays in discharging patients (known as ‘delayed transfers of care’) are one of the factors that drives up bed-occupancy rates, preventing beds being freed up for those who need to be admitted, and adding to pressures on A&E departments.
The number of delayed transfers of care was relatively stable up until the start of 2014/15 but since then the total number of delayed days has increased by 68 per cent and in quarter 3 2016/17 reached its highest level since 2007. There has been a particularly steep increase this year, with delayed days rising 16 per cent (equivalent to 27,600 extra delayed days) between April and December 2016 (Figure 5).
While the majority of delayed transfers can be attributed to delays within the NHS (58 per cent so far in 2016/17), the proportion attributable to social care has risen recently (from 26 per cent at the end of 2014/15 to 34 per cent in 2016/17). This reflects pressures faced by local councils, which have seen significant cuts to their budgets in recent years.
Though these are the official figures released by NHS England, there have been questions raised as to how well the data captures all delayed transfers of care. The Carter review, National Audit Office and the Nuffield Trust have all suggested the scale of the problem could be much worse than reported in the official figures, with the Nuffield Trust recently suggesting that the number of delays could be up to three times higher than reported by NHS England.
Are A&E pressures due to staff shortages?
A&E departments have faced difficulties in recruiting and retaining staff.
Since 2013, Health Education England and the Royal College of Emergency Medicine have been working together to address workforce shortages in emergency medicine, with a focus on encouraging more medical students to choose emergency medicine as a career. Information from Health Education England suggests that the actions taken so far have had a positive impact, resulting in 98 per cent of training posts being filled.
However, staffing issues remain a significant concern. The Royal College of Emergency Medicine reports that, while recruitment into emergency medicine is now high with most first-year emergency medical training posts being occupied, problems with retention mean it has the greatest attrition rate of any medical specialty, with almost 50 per cent of registrar doctors in their third and fourth years of training resigning. This is of particular concern given the direct contribution these staff make to the delivery of care, and their position as the emergency medicine consultants of the future. While Monitor’s recent analysis (2015) concluded that this did not contribute to the longer waits experienced in 2014/15, most A&E departments are working at a very high level of activity, and there is a limit to the workload staff can undertake without having negative consequences on morale, recruitment and retention, performance and/or patient safety.
A&E waiting times have been increasing over time, with figures for quarter 3 2016/17 (October to December 2016) showing that the proportion of people waiting longer than four hours has reached its highest level in more than a decade. Furthermore, in 2016/17 the NHS is certain to miss the standard for the third year running.
The causes of the problems in A&E, and the solutions to address them, are complex. It is often assumed that performance against the four-hour standard has deteriorated due to an increase in attendances, including by some people who could be better treated elsewhere. However, for many hospitals this is not the primary factor impacting on waiting times. A&E is in constant interaction with other hospital departments (for example, to request diagnostic tests and/or to transfer patients to beds in other parts of the hospital). A&E performance is therefore dependent on processes and capacity in other hospital departments, as well as other parts of the health and care system.
The number of people needing to be admitted from A&E into a hospital bed has increased over time, with rates tending to be highest in the winter. This is particularly a problem in hospitals when the bed-occupancy rate is already high as there are no free beds to admit these patients to. While there are a number of factors driving bed-occupancy rates up, delays in discharging patients from hospital and back into their homes or another more appropriate setting (such as social care) are a particular concern.
A&E is often described as the barometer of the NHS. The significant decline in performance in recent years is not due to a single cause – rather it is the result of a combination of factors that reflect the huge pressures on the health and care system.
Further resources on urgent and emergency care
- Watch our animation: An alternative guide to the urgent and emergency care system in England
- See all of our commentary and analysis on urgent and emergency care
- Read our Quarterly monitoring report
- Watch our animation: An alternative guide to the new NHS in England